DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
PULP CAPPING AND PULPECTOMY Carious involvement of the pulp of deciduous and permanent teeth of children and adolescents pose another restorative chal- lenge. Bacterial infiltration of the dental pulp initially presents with an inflammatory response that will culminate in the necrosis of the pulpal tissues. A localized abscess can form and evolve into cellulitis, which follows muscle and fascial planes and can ultimately lead to a disseminated systemic infection. In adults, carious involvement of the pulp of permanent teeth with fully formed roots is treated by root canal therapy or by extraction. While conventional root canal therapy cannot be performed on retained deciduous teeth or permanent teeth in which the roots are not completely formed, other procedures are available to treat pulpal tissue that has carious involvement. Carious lesions that approach the pulp in a deciduous tooth can be treated by an indirect pulp capping technique. This procedure entails the removal of all of the carious dentin except the layer closest to the pulp. A medicament such as calcium hydroxide or zinc oxide-eugenol (ZOE) is then applied directly against this deepest layer of remaining caries. These compounds stimulate the pulp to produce reparative dentin beneath the carious lesion to stop the progression of caries and maintain pulpal vitality [17]. This technique can be done in one appointment, with amalgam or composite resin restoration placed over the layers of ZOE or calcium hydroxide. Another approach involves the placement of a temporary restoration over the ZOE or calcium hydroxide with a return visit in six to eight weeks to excavate any residual carious dentin and place the final restoration [18]. A direct pulp cap may be used when a carious lesion extends directly into the pulp of an otherwise healthy tooth without symptoms (e.g., pain, sensitivity to extremes of temperature). A material such as calcium hydroxide is applied directly to the area of pulpal exposure to stimulate reparative dentin [19]. This procedure usually has a poor prognosis in deciduous teeth, and if ineffective, a pulpotomy should be utilized. A pulpotomy is a procedure in which the entire inflamed coronal pulp is removed while the pulpal tissue within the roots is left intact. Upon removal of all caries and the achieve- ment of hemostasis within the pulp chamber, mineral trioxide aggregate (MTA), formocresol, or ferric sulfate is applied with either cotton pellets or a specific carrier directly to the pulpal tissue stumps until a clot forms. The tooth is subsequently restored with a base, such as intermediate restorative material (IRM). The ideal final restoration is a stainless steel crown for deciduous molars or an anterior strip crown for anterior teeth. The treatment of extensively carious immature permanent teeth, for which root formation and closure are years away, also presents as a unique restorative challenge. Immature permanent teeth with carious lesions that approach the pulp but with no or minimal symptoms can be treated with the one- or two-step indirect pulp technique. If a stainless steel crown or an anterior strip crown is utilized for the immediate
restoration, it must be replaced by a permanent crown after root formation is complete. If the removal of the carious lesion causes a small (pinpoint) exposure to the pulp, with symptoms of pain, the direct pulp cap technique can used for immature permanent teeth [20]. Direct pulp caps of immature permanent teeth have a much better prognosis when compared to those of deciduous teeth. When an extensive carious lesion involves the pulp of imma- ture vital (non-necrotic) permanent teeth, the therapeutic goals are to eliminate pain and to provide treatment that will allow for the complete development of the root, including apexogenesis. This can only occur if the radicular pulp is left in a healthy state. After the inflamed pulpal tissue is removed, a layer of calcium hydroxide or MTA is placed over remaining exposed pulpal tissue [21]. A base (e.g., IRM) and a composite resin restoration complete the coronal seal. Periodic radiographic assessment is necessary to evaluate the continuity of root formation and apexogenesis. Some teeth restored in this fashion may remain asymptomatic and exhibit no apical pathology, while others will require conventional root canal therapy after the root apex has completed its formation. EXTRACTION Caries in deciduous and immature permanent teeth may progress to the point that the tooth is no longer restorable and must be extracted. Although deciduous teeth are designed to be shed, they maintain an important role in occlusion and phonation. Unrestorable deciduous teeth should be extracted before causing drifting of adjacent teeth or creating an obstacle to the eruption of permanent teeth. A classic example of this occurs with the premature loss of deciduous second molars. Because the maxillary and mandibular permanent first molars erupt long before the anticipated exfoliation of the deciduous second molars, which are eventually replaced by the permanent second bicuspids, the premature loss of second deciduous molars allows the permanent first molars to drift mesially and create an obstacle to the eruption of the permanent second bicuspids. A space maintainer may be necessary to prevent this occurrence. The space maintainer is cemented onto the permanent first molar and is removed after the permanent second bicuspid has erupted to a position that will prevent mesial drift. APEXIFICATION Carious lesions that are left untreated will eventually cause necrosis of the coronal and radicular pulp. Necrotic (non-vital) immature permanent teeth present a unique challenge, as the non-vital radicular pulpal tissue cannot contribute to further development of the root and apexogenesis. In these cases, an apexification procedure is used. Conventional root canal therapy cannot be completed because the root of the imma- ture permanent tooth has an open apex that cannot provide a definitive stop for obturation material. The apexification procedure is designed to create a definitive calcified stop in the apical region of the root, which would then allow gutta percha to be used to complete definitive root canal therapy.
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